Fight or flight?

Several years ago, when a surgeon refused to see one of his patients in a timely manner,
a frustrated Eric E. Howell, MD, FACP, decided to complain to the surgeon's boss,
who forced the surgeon to comply. His actions permanently damaged his relationship
with the surgeon, but Dr. Howell felt it was a fight worth picking for the good of
the patient.

“The relationship was ruined but the patient might have died if I hadn't competed
to win,” said Dr. Howell, chief of hospital medicine at Johns Hopkins Bayview
Medical Center in Baltimore. The incident taught him a valuable lesson about dealing
with conflict, he added: “Sometimes what's more important than the relationship
is the actual outcome of the negotiation, particularly when it comes to patient safety
and harm.”

Photo by Thinkstock.

Hospitalists often face this kind of dilemma when a dispute arises with a colleague:
Do you try to make everyone happy, or risk ruining a relationship to get what you
need? Dr. Howell was driven to act in order to protect a patient, but other potential
disputes may not be worth a fight, he noted.

“If the relationship is more important than what you're arguing over, then
what [you] lose in accommodating [you] gain in building relationship capital,”
said Dr. Howell, who has led several conference sessions for hospitalists on conflict
management and negotiating skills.

Conflict may be uncomfortable, but it is a fact of life for hospitalists who must
work with colleagues in every part of the hospital to coordinate patients' care. Instead
of avoiding it, experts advise developing negotiating strategies that can turn conflict
into a tool for positive change.

Know your negotiating style

Engaging in conflict with colleagues is really about managing relationships, noted
Erik A. Wallace, MD, FACP, associate program director of the department of internal
medicine at the University of Oklahoma School of Community Medicine in Tulsa. To be
successful, you must know your own and your colleague's negotiating styles, he added,
because “you can't be great at managing relationships if you lack self-awareness.”

Your dominant style represents your natural tendencies in dealing with conflict, but
you can still shift to other styles when necessary, Dr. Wallace noted, depending on
the nature of the conflict or the importance of the outcome. Imagine, for example,
that when you start your shift you discover a patient's nighttime insulin was not
administered, he said.

“If I lacked self-awareness, my first response might be to blame the nurse,
but a self-aware person might say first, ‘I'm typically pretty aggressive and
I need to understand that going in to be effective. I need to investigate what's going
on and manage my emotions.’ Then approach the nurse and ask questions,”
Dr. Wallace said.

While it might turn out that the nurse simply forgot the order, a careful investigation
might also reveal that the patient's blood sugar was too low or the insulin wasn't
delivered on time to the unit or the patient refused treatment, said Dr. Wallace.
“There's a whole list of possibilities. If the physician is receptive and understanding,
the nurses may be more willing to come forth and explain what happened. But if he
is perceived as aggressive and belittling, they may be reluctant to communicate when
things don't go well,” he said.

Different situations dictate whether or how to modify your natural negotiating style.
For example, it might be wise to avoid a potential conflict when there is a power
differential, said Dr. Howell, such as between a staff hospitalist and the chief financial
officer of the hospital.

“If I suspect he's going to ask me about a cost reduction program and I don't
have that skill set, I may avoid him at first and enlist my physician boss before
I engage in a conversation,” he said. “When you're dealing with someone
with more power than you, it's wise to seek out someone else on the same power level,
such as the chair of medicine, as your advocate who can either come with you to a
meeting or tell you what your options are.”

Aside from deciding on a conflict management style, physicians should go into negotiations
armed with objective data, said Kenneth G. Simone, DO, principal at Hospitalist and
Practice Solutions, a national practice management consulting firm based in Veazie,
Maine.

He recommended always separating the person from the problem and being prepared to
consider alternative solutions in order to achieve a desired outcome.

Emotionally charged disputes can erupt when two groups have different incentives or
motivations, Dr. Simone said. For example, conflicts often arise between emergency
department (ED) physicians, who are under pressure to reduce patient wait times, and
hospitalists, who are under equal pressure to discharge patients by midday, which
may delay their response time in the ED.

“The admitting provider, the hospitalist, has a different goal or incentive
than the ED physician,” said Dr. Simone. In order to avoid a major conflict,
both sides need to reassess their positions and realize that they have a common goal:
to best service the needs of the patient, he said.

Leading by example

Hospitalists have a leadership role in creating an environment conducive to resolving
and managing conflicts, said Leonard J. Marcus, PhD, director of the program for health
care negotiations and conflict resolution at Harvard School of Public Health in Boston
and co-author of “Renegotiating Health Care: Resolving Conflict to Build Collaboration.”
“They are required to build connectivity of effort among all others in the
hospital—nurses, specialists, social workers, patients, families—to
ensure high-quality, efficient care,” he said.

To foster that environment, he said, hospitalists must be prepared to put their own
feelings or biases aside and help others when emotions take over during a conflict.
For example, a decision to discharge a patient before either the physician or the
family feels she is ready can cause everyone involved to feel threatened and go to
their emotional “basement,” where raw emotion dominates, he said.

To move a conflict forward, the hospitalist must identify when others are in their
emotional “basement” and take steps to get them out of that state. That
might mean helping an older patient understand why patients are discharged earlier
now than in the past and what supports she will have in the home to provide ongoing
care.

Hospitalists' leadership role makes it especially important for them to know when
and how to switch among different negotiating styles, said Dr. Howell.

“If you continually avoid and accommodate, for example, the real damage comes
to your effectiveness as a leader,” he said. “People will start to walk
all over you. They will always negotiate with you and take what you have. If you avoid,
you can be seen as passive-aggressive and you will lose the trust of people you are
leading because they become frustrated with you.”

While avoiding a potential conflict or difficult situation often seems like the easiest
solution, the resulting unresolved feelings can have lasting repercussions, said Dr.
Wallace. “When those feelings stew and fester for a long time, people aren't
happy or satisfied with what they're doing. But if you engage in the hard conversation,
you can move on with your life,” he said.

Successful conflict management is also integral to a successful career, said Dr. Marcus.

“Often people view the role of the hospitalist in terms of what they bring
to clinical care, but one very important parameter of success is understanding social
care in hospitals,” he said. “It's the combination that is so powerful—those
who have top clinical skills with the capacity to engage in a complex social environment
will be the most successful leaders within their institution.”

Online resource offers help with conflict resolution

Thomas-Kilmann's five conflict management styles

Accommodating

If your dominant style is accommodating, you dislike the impact that differences between
people may have on their relationships. You believe that self-sacrifice and placing
the importance of continued relationships above one's own goals is necessary for solving
conflict.

Competing

If your dominant style is competing, you see differences among people as reflecting
their skills: Some people have skills, others have none; some are right and some are
wrong. You believe that you owe it to yourself and to those who rely on your judgment
to prevail in conflicts with others whose opinions and goals are in doubt.

Avoiding

If your dominant style is avoiding, you probably had bad experiences with either accommodating
or competing, or you see conflict as the results of people's preferences and aspirations—and
thus, beyond influence. Conflict is seen as a necessary evil that we must either accept
or withdraw from.

Compromising

If your dominant style is compromising, you believe that differences between people
should be treated in light of the common good and that parties need to “win
a little, lose a little.” This style tries to soften and make more tolerable
the effects of losing by limiting the gains. Both ends are played against the middle
in an attempt to serve the common good.

Collaborating

If your dominant style is collaborating, you believe that conflict itself is neither
good nor bad, but usually a symptom of tensions in relationships. When properly interpreted,
differences may be resolved and can serve to strengthen relationships rather than
divide.

More information about the Thomas-Kilmann Conflict Mode Instrument is online.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.